Northern California Napa/Solano Area Sponsorship Application Introduction Welcome! Kaiser Permanente supports a range of activities to enrich the health of our communities. Through our local grants program, we support, strengthen and enhance programs and organizations that address the health needs of our most vulnerable residents. The Napa-Solano area includes the Solano County communities of Benicia, Dixon, Fairfield, Rio Vista, Suisun City, Vacaville, and Vallejo, and the Napa County communities of American Canyon, Calistoga, Napa, Oakville, Rutherford, St. Helena, and Yountville. Through a community needs assessment, we identify priority health and social needs to guide our contributions to the community. The health priority needs identified through 2017 are: Healthy Eating and Active Living Access to health care services Behavioral Health (includes mental health and substance abuse) Community and Family Safety Click Next to start your online application General Organization Information Basic Information Organization Name Please enter the name by which your organization does business as.
Organization Street Address Please provide your organization's physical street mailing address and any suite or floor number. 401 Bicentennial Way City State CA Zip Code Organization's General Phone Number Phone number format: (###) ###-#### Phone Extension If applicable Organization's General Fax Number Please enter your fax number in the following format: (###) ###-#### Organization's Main E-mail Address Organization's Web Address Chief Executive Officer/Executive Director Contact Information Prefix First Name Last Name Suffix <None> Title Phone Extension If applicable E-mail Chief Executive's Mailing Address Complete the mailing address information only if the chief executive's address is different from organization's address City State <None> Zip code Tax Status Organization's Legal Name This is the name that appears on your IRS Determination letter, other leagal documentation, or Form 990.
Organization's Tax ID# (EIN or TIN) ##-####### Tax Status Select your organization's tax status from the pull-down list below. If you use a fiscal agent, select "Other" and complete the Fiscal Agent information below. 501(c)(3) Tax Exempt Status Letter One of the following documents must be submitted: For nonprofit organizations, one of the following documents must be submitted: Copy of current IRS determination letter indicating appropriate tax-exempt status with Tax ID number; OR Copy of IRS Form 1023 that documents recognition of tax exemption under 501(c)(3) and that the organization is classified as a public charity (not a private foundation), under section 509(a). For government/public entities, one of the following documents must be submitted: Copy of the IRS affirmation letter with the Federal Identification Number; OR a Notarized letter from the organization's Chief Financial Officer or Certified Public Accounting Firm indicating the government/public agency has been granted tax exemption; OR Copy of the statute or enabling legislation establishing the entity Fiscal Agent (optional) If your organization will be using a fiscal agent, please complete the following information. If not, please click 'Next' (at the bottom of the page.) Fiscal Agent's Legal Organization Name As it appears on the IRS determination letter or Form 990 Fiscal Agent's Tax ID# xx-xxxxxxx Fiscal Agent's Mailing Address Street Address, City, State, and Zip Code (9-digit code, if known.) Fiscal Agent's Contact Prefix, First and Last Name of the Chief Executive of the Fiscal Agent Title of Contact
Contact Phone Number Please use the following format: (###) ###-#### Contact Email Fiscal Agent MOU Please upload a copy of the memorandum of understanding between the fiscal agent and your organization. Fiscal Agent Tax Exempt Status Letter Please upload a copy of the IRS tax exempt status determination letter for the fiscal agent or IRS Form 1023 for both fiscal agent and requesting entity (if these exist) Compliance Compliance Information Do any Kaiser Permanente executives, managers, directors, physicians or other employees or their family members: Serve as a board member, director, officer, manager, employee or fiduciary agent of your organization; or Have a compensation arrangement or financial interest with your organization If yes, please provide the person(s) name and describe the nature of the relationship. Non Discrimination Policy By selecting YES below, the organization attests that it does NOT discriminate on the basis of race, color, national origin, sex/gender, sexual orientation, age, physical or mental disability, in their programs, services, policies, hiring practices and administration. Non Proselytizing (for religious or faith-based organizations) Your program or service must be open to the general public and aimed at addressing a
community need, and Programs and services are provided regardless of an individual s religious affiliation or belief, and Individuals are not required to attend or participate in services, classes or sessions where the purpose is to promote, teach or advance a religious doctrine or philosophy Will any portion of your contribution request be used to further religious doctrine, or for programs for the congregation, members or students or in the support of general operations? Yes Board of Directors Please upload a list of your organization's directors, officers, or individuals on the governing body and their affiliations, if any, to KFHP/KFH or The Permanente Medical Group and its subsidiaries. Key Project Staff/Volunteers Please upload a list of key project staff and volunteers by name, title and qualification. Specific Organization Information Organization History Organization's History Brief summary of your organization's history (150 word max) xxxxxx Year Founded If you do not know the exact date, please use January 1st of the year of establishment. Organization's Mission Statement (100 word maximum) xxxxxxxx
Current Programs and Activities Describe the organization's current programs and activities and the population served. (100 word maximum) xxxxxxxx Annual Total Organization Budget Event/Sponsorship Primary Contact Please check this box if the contact for the event or project is the same as the contact you provided above. No Prefix First Name Last Name Suffix <None> Title Phone Please use format: (###) ###-#### Extension If applicable. Fax Please enter your fax number in this format: (###) ###-#### Email Event/Project Sponsorship Information Event Information Event/Project Title (input titles for all events/projects you are applying for) If you are applying for multiple events, please input the information for all of the events into the fields below.
Event/Project Type Please select the code that best describes the event/project for which you are seeking sponsorship. If applying for multiple events/projects, select "other" and input the types below. For Other (please specify) Event/Project Summary Please describe all of the events or projects you are seeking sponsorship for. Event/Project Dates and Times Please list all event/project dates along with specific start/end times. Event/Project Location and Address Please list each location where each event/project is taking place. Event Agenda/Program Please upload an overview of each event schedule, including details such as program start time, meal start, networking or reception times, and any other details available regarding the event agenda. Amount Requested Please enter the amount of funding you are requesting from Kaiser Permanente. Request on Organization's letterhead The request on organization's letterhead should include the legal name of organization, organization's address, requested amount, project title and how the funds will be used. If a fiscal agent is being used, then the request and required information must also be submitted on the fiscal agency's letterhead. Sponsorship Levels and Benefits Please upload a detailed listing of event sponsorship levels and their associated benefits. In-Kind Support Requested Kaiser Permanente provides the following types of in-kind support: 1. Promotional items 2. Use of the "Kaiser Permanente in the Community" logo if the event/project meets the eligibility criteria 3. Speakers for the event/project If you are looking for in-kind support, please describe which types of support you are requesting for each event or project you are applying for and be as detailed as possible (i.e. number of items needed, where logo would
be used, what type of speaker you would like and for what topic). Partners Please describe any community partners involved in the coordination and/or provision of each event or project (please list and describe briefly). Other Kaiser Permanente Funding If you are a current grantee or you have already received a sponsorship from Kaiser Permanente for an activity in 2013, please explain how this investment aligns and/or enhances existing investments. Please include a list of both local and regional funding. Commitment Date Please list each date by which your organization must be notified of sponsorship decisions, for each event/project you are applying for. Napa/Solano Event Activation form Click here to download the required Napa/Solano Event Activation form. Submissions without the activation form will not be considered. Expected Outcomes How Dollars Will Be Spent (1)Please indicate the total amount of funding requested for each event/project and (2)provide details on how sponsorship dollars will be spent for each event/project. (i.e. Forum cost is $2,000: $1,000 for media and promotion and $1000 for production for forum materials) Event/Project Goals and Objectives Please list the goals and objectives of each project/event you are applying for.
Success Measurement For each event/project please describe how the success of the event/project will be measured. Please include intended results or outcomes for each objective mentioned under the Event/Project Goals and Objectives section. Number of People Expected to Reach or Serve Tangible Benefit Fair market value of tangible benefit items, if applicable. For example, please provide the fair market value of each meal, conference ticket, and/or booth. Please enter the dollar value and the description. Enter "not applicable" if no goods or services will be provided to our organization as part of the sponsorship. Visibility Briefly describe any plans to communicate each event or project to an external audience and/or how you will acknowledge Kaiser Permanente for its support for each separate event or project (e.g., newsletters, media coverage, presentations). Other Items Other Attachement #1 Please upload any other items that you wish us to consider when making a decision about your event/sponsorship. Other Attachement #2 Please upload any other items that you wish us to consider when making a decision about your event/sponsorship.
Demographics Demographics Target Audience Briefly describe the target audience for each project/event you are applying for. Areas Served Please indicate what neighborhoods or geographic communities are being reached by your event or project. Community Building Please indicate if your event/project is a community building activity by checking the applicable category below: Population Served Please select the top three (3) populations your sponsorship will impact, with the primary population selected first. Age Group of the Population Served If your request will serve all ages listed, please select "All." Otherwise, please select all that apply, with the primary population selected first. Ethnicity of the Population Served Please select all that apply, with the primary population selected first. Please select "Other" if the request serves an ethnicity not listed. Gender of the Population Served If your request will serve all genders listed, please select "All." Otherwise, please select all that apply, with the primary population selected first.